MINDSCREEN FILM INSTITUTE APPLICATION

No.4, (Old No.51), Ranga Lane, Off Dr.Ranga Road, Mylapore, Chennai – 600 004 NUMBER
Telephone: +91 44 42108682 / 24996417, Fax: +91 44 24310655, Mobile: +91 9841612595
E-mail: mindscreen@mindscreen.co.in, Web: www.mindscreen.co.in

APPLICATION FORM
CHECKLIST FOR FILLING UP THIS APPLICATION FORM
 APPLICATION TO BE FILLED IN LEGIBILY AND MUST BE COMPLETE.
 REQUIRED RELEVANT DOCUMENTS TO BE ATTACHED WITHOUT FAIL. RECENT
 ACADEMIC CERTIFICATES AND EXPERIENCE CERTIFICATE IF ANY.
 ONLY XEROX COPIES OF DOCUMENTS TO BE ATTACHED. PASSPORT SIZE
 AGE PROOF (BIRTH CERTIFICATE/SCHOOL LEAVING CERTIFICATE/DRIVING PHOTOGRAPH
LICENCE.)
 PROOF OF IDENTITY (PHOTO PAN CARD / VALID PASSPORT /VOTERS IDENTITY
CARD.)
 REGISTRATION AND APPLICATION FEE*.
 STATEMENT OF PURPOSE.

REGISTRATION AND APPLICATION FEE*(Payment by DD or Bank transfer for outstation and International
Students).The registration and application fee of Rs.2500.00 inclusive of service tax is non – refundable and all payments to be
made favoring MINDSCREEN FILM INSTITUTE, CHENNAI along with this duly filled in application.

*REGISTRATION AND APPLICATION FEE PAYMENT (PLEASE TICK THEAPPROPRIATE)

BANK TRANSFER DEMAND DRAFT CASH OTHERS
CHOICE OF SPECIALIZATION CINEMATOGRAPHY SCREENWRITING & FILMMAKIMG
FOR OFFICE USE (REGISTRATION AND APPLICATION FEE CONFIRMATION)

RECEIPT NUMBER: DATED: Rs. MODE OF PAYMENT:

APPLICANT’S PERSONAL DETAILS
FIRST NAME MIDDLE NAME SURNAME SEX
M F
DATE OF THE BIRTH NATIONALITY MOTHER TONGUE MARITAL STATUS
Day Month Year MARRIED SINGLE

CONTACT AND COMMUNICATION DETAILS OF THE APPLICANT

MAILING ADDRESS PERMANENT ADDRESS

APPLICANT’S E-MAIL ID MOBILE NO

APPLICANT’S DRIVING LICENCE NO APPLICANT’S PASSPORT NO

APPLICANT’S VOTER ID NO APPLICANT’S PAN CARD NO BLOOD GROUP

APPLICANT’S LANGUAGE SKILLS APPLICANT’S COMPUTER SKILLS
READ WRITE SPEAK ADOBE PHOTO SHOP ADOBE PREMIERE MS OFFICE

EXCELLENT EXCELLENT EXCELLENT

GOOD GOOD GOOD
AVERAGE AVERAGE AVERAGE

NIL NIL NIL

 DETAILS OF EDUCATIONAL QUALIFICATION FROM MATRICULATION /SSLC/SSC ONWARDS
EXAMINATION UNIVERSITY/BOARD/ SUBJECTS YEAR OF DIVISION/
% MARKS
PASSED INSTITUTION/COUNS PASSING CLASS/GRADE

OTHER SKILLS (PLEASE TICK)

DIGITAL PHOTOGRAPHY (DSLR) GOOD AVERAGE NIL
VIDEO EDITING
SOUND RECORDING
IMAGE EDITING
HAVE YOU ATTENDED ANY WORKSHOP OR SEMINAR? IF YES, PLEASE SPECIFY

WHETHER STUDIED EARLIER IN ANY OTHER FILM INSTITUTE? IF YES NAME AND ADDRESS
OF THE INSTITUTE AND SPECIALIZATION

HAVE YOU ATTENDED ANY FILM FESTIVAL? IF YES PLASE FURNISH DETAILS

HAVE YOU PREVIOUSLY APPLIED FOR ADMISSION AT MINDSCREEN FILM INSTITUTE? YES NO

IF EMPLOYED, PLEASE FURNISH YOUR EMPLOYMENT DETAILS

ARE YOU RELATED TO ANYBODY IN THE FILM INDUSTRY? IF YES PLEASE FORNISH DETAILS

ON COMPLETION OF THE COURSE, HOW DO YOU INTEND TO GET INTO THE FILM INDUSTRY?
SHORT FILM, MUSIC VIDEO, DOCUMENTARY WRITTEN/DIRECTED OR SHOT BY YOU

STATEMENT OF PURPOSE TO WHY YOU WISH TO TAKE UP A CAREER AS A CINEMATOGRAPHER

/SCREENWRITER OR DIRECTOR IN 200 WORDS STRICLY.

PARENT’S /GAURDIAN’S PERSONAL INFORMATION

PARENT’S /GAURDIAN’S NAME
PARENT’S /GAURDIAN’S NAME OCCUPATION
PARENT’S /GAURDIAN’S ANNUAL INCOME Rs.
ADDRESS FOR COMMUNICATION PERMANENT ADDRESS

PARENT’S /GAURDIAN’S E-Mail ID:

PARENT’S /GAURDIAN’S MOBILE No: PARENT’S /GAURDIAN’S LANDLINE No:
DECLARATION
I solemnly affirm that the information given in this application is true to the best of my knowledge and belief. I
understand that the decision of the institute is final with regard to the admission and assignment to a particular
course of study. If selected for admission, I promise to abide by the rules, regulations and directives of the Institute
and pay all applicable fees before commencement of the course.

SIGNATURE OF THE APPLICANT: Date:

Place: